Surgical debridement alone does not adequately reduce planktonic bioburden in chronic lower extremity wounds

Objective: It is commonly believed that sharp surgical debridement provides adequate bacteria control for local wound beds, despite limited supporting scientific evidence. We undertook a prospective study to evaluate the reduction in planktonic bacteria pre- and post-operative debridement in critically colonised wounds.Method: Twelve patients, corresponding to 14 wounds, underwent debridement with either hydrodebridement or sharp steel debridement with pulse irrigation. Wound quantitative tissue cultures were taken pre- and post-debridement. There was no significant difference in wound aetiology or surface area between the two groups.Results: The bacterial counts before debridement were 1x107 colony-forming units per gram (CFU/g) in the hydrodebridement group vs 1.4x107 CFU/g in the sharp debridement group; and 2.5x106 CFU/g (hydrodebridement) vs 7.5x105 CFU/g (sharp) after debridement (p=0.41). The total bacteria reduction was 7.5x106 CFU/g after hydrodebridement vs 1.3x107 CFU/g after sharp steel debridement (p=0.37). The mean percentage of bacteria killed from baseline was 75% by hydrodebridement and 93% killed by sharp debridement (p<0.05).Conclusion: Extensive operative debridement using either modality does not provide adequate immediate reduction in wound planktonic bioburden. However, all wounds appeared clinically appropriate for closure after debridement and postoperative antibacterial therapy. Postoperative antibacterial therapy may be imperative in cases of critically colonised wounds to achieve good outcomes

When are concerted reforms feasible?: Explaining the emergence of social pacts in Western Europe.

Under what conditions do governments, employers, and unions enter formal policy agreements on incomes, employment, and social security? Such agreements, widely known as social pacts, became particularly prominent during the 1990s when European economies underwent major adjustment. This article seeks to explain national variation in adjustment strategies and specifically why concerted agreements were struck in some countries but not in others. A fuzzy-set qualitative comparative analysis of 14 European countries is employed to assess main arguments about the emergence of pacts. The analysis yields two key findings. First, although prevailing arguments emphasize Economic and Monetary Unionrelated pressures, or alternatively unemployment, these factors were neither necessary nor in themselves sufficient for pacts to materialize. Rather, a high economic problem load appears to be causally relevant only when combined with particular political and institutional conditions, namely, the prevalence of electorally weak governments and/or an intermediate level of union centralization. Second, the analysis refines existing multicausal explanations of pacts by demonstrating three distinct, theoretically and empirically relevant causal pathways to concerted agreements

Negative pressure wound therapy with instillation (NPWTi) better reduces post-debridement bioburden in chronically infected lower extremity wounds than NPWT alone

Objective An overabundance of bacteria in the chronic wound plays a significant role in the decreased ability for primary closure. One means of decreasing the bioburden in a wound is to operatively debride the wound for wound bed optimization prior to application of other therapy, such as Negative Pressure Wound Therapy (NPWT). We undertook a prospective pilot study to assess the efficacy of wound bed preparation for a standard algorithm (sharp surgical debridement followed by NPWT) versus one employing sharp surgical debridement followed by Negative Pressure Wound Therapy with Instillation (NPWTi). Methods Thirteen patients, corresponding to 16 chronic lower leg and foot wounds were taken to the operating room for debridement. The patients were sequentially enrolled in 2 treatment groups: the first receiving treatment with operative debridement followed by 1 week of NPWT with the instillation of quarter strength bleach solution; the other receiving a standard algorithm consisting of operative debridement and 1 week of NPWT. Quantitative cultures were taken pre-operatively after sterile preparation and draping of the wound site (POD # 0, pre-op), post-operatively once debridement was completed (POD # 0, post-op), and on post-operative day 7 after operative debridement (POD # 7, post-op). Results After operative debridement (post-operative day 0) there was a mean of 3 (±1) types of bacteria per wound. The mean CFU/gram tissue culture was statistically greater - 3.7 × 106 (±4 × 10 6) in the NPWTi group, while in the standard group (NPWT) the mean was 1.8 × 106 (±2.36 × 106) CFU/gram tissue culture (p = 0.016); at the end of therapy there was no statistical difference between the two groups (p = 0.44). Wounds treated with NPWTi had a mean of 2.6 × 105 (±3 × 105) CFU/gram of tissue culture while wounds treated with NPWT had a mean of 2.79 × 106 (±3.18 × 106) CFU/gram of tissue culture (p = 0.43). The mean absolute reduction in bacteria for the NPWTi group was 10.6 × 106 bacteria per gram of tissue while there was a mean absolute increase in bacteria for the NPWT group of 28.7 × 106 bacteria per gram of tissue, therefore there was a statistically significant reduction in the absolute bioburden in those wounds treated with NPWTi (p = 0.016). Conclusion It has long been realized that NPWT does not make its greatest impact by bioburden reduction. Other work has demonstrated that debridement alone does not reduce wound bioburden by more than 1 Log. Wounds treated with NPWTi (in this case with quarter strength bleach instillation solution) had a statistically significant reduction in bioburden, while wounds treated with NPWT had an increase in bioburden over the 7 days. © 2014 Elsevier Inc. All rights reserved

Social pacts on the road to EMU: A comparison of the Italian and Polish experiences

In the new EU member states, tripartite national-level social pacts have been promoted as a preferred and effective instrument for a rapid and relatively painless fulfilment of the Maastricht criteria, following the example of many of the old member states in the 1990s, and notably Italy. But such policy advice is not based on careful comparisons. By comparing Poland and Italy, this article undermines the dominant view that the failure of concertation attempts in Poland is mostly due to trade union politicization. The comparative test with Italy, a country with equally politicized trade unions, and where, by contrast, important social pacts have been signed, suggests that divergent employer strategies and organization are at least an equally important factor. Additionally, the study provides a more mixed assessment of the Italian social pacts